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10/9/2019 Point of Care Ultrasound UCSF Continuing Medical Education Abdominal Imaging and Procedures Brandon Boesch, DO Disclosure I have no relevant financial relationships with any companies related to the content of this course. 1

10/9/2019 3 Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier Areas to Identify Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 4 2

10/9/2019 Probe Selection Phased Array Curvilinear 5 Probe Position - Knuckles on the bed - Adjust probe angle for view between ribs and take into account the angle of abdominal organs 6 3

10/9/2019 Probe position 7 8 4

10/9/2019 Normal RUQ View Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 9 RUQ/Perihepatic view Normal Abnormal 10 5

10/9/2019 RUQ/Perihepatic view Normal Abnormal 11 RUQ/Perihepatic view Normal Abnormal 12 6

10/9/2019 RUQ/Perihepatic view Normal Abnormal 13 RUQ/Perihepatic view Normal Abnormal 14 7

10/9/2019 Gallbladder Can be a very challenging exam False positives are very common in hospitalized patients Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 15 Gallbladder 16 8

10/9/2019 Wall Echo Shadow 17 Gallbladder or something else? 18 9

10/9/2019 Normal LUQ Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 19 LUQ Positioning 20 10

10/9/2019 21 LUQ/Perisplenic view Normal Abnormal Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 22 11

10/9/2019 LUQ/Perisplenic view Normal Abnormal Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 23 Goals for Scanning Stations - Identify all the structures in RUQ and LUQ - Look for the large vessels and spine deep on the image - Practice scanning the gallbladder. Find and name structures that you do know. 24 12

10/9/2019 Kidney Anatomy  2 Anatomical Sections ➔ Sonographic “Double Density”  Renal Parenchyma = Cortex + Medulla  Renal Sinus = Fatty tissue + Calyces + Vessels Image Acquisition From Point-of-Care Ultrasound, 1 st edition, 2014 13

10/9/2019 Normal Kidneys 1. Perinephric fat + Gerona's fascia = hyperechoic 2. Renal cortex = hypoechoic 3. Medullary pyramids = hypo-/anechoic 4. Renal sinus = hyperechoic with small pockets of urine (not contiguous) and vessels 5. Ureter normally obscured by bowel gas Normal 14

10/9/2019 Renal Pathologies  Atrophy  Hydronephrosis  Stone  Cysts  Mass Atrophic Kidney 15

10/9/2019 Hydronephrosis  Mild = central dilation with preservation of renal pyramids  Moderate = blunting of renal pyramids, rounding of calices, “bear-claw” appearance, preservation of cortex  Severe = cortical thinning, calyceal ballooning, distortion of architecture Mild Hydronephrosis From Point-of-Care Ultrasound, 1 st edition, 2014 16

10/9/2019 Severe Hydronephrosis From Point-of-Care Ultrasound, 1 st edition, 2014 Bladder  Indications  Estimate bladder volume  Confirm catheter placement  Ureteral obstruction (ureteral jets)  Detect stones  Work-up for renal failure 17

10/9/2019 Bladder Anatomy  Posterior and inferior to symphysis pubis (tilt US beam into pelvis)  Ureters enter trigone on postero-inferior From Point-of-Care Ultrasound, 1 st edition, 2014 wall  Prostate normally <5cm transversely Image Acquisition Transverse View Longitudinal View 18

10/9/2019 Normal Male Bladder Transverse View Foley + Decompressed Bladder 19

10/9/2019 Distended Bladder + Foley + Enlarged Prostate Bladder Volume Estimation Volume (ml) = 0.75 x width x length x height Transverse View Longitudinal View 20

10/9/2019 Anatomy of Aorta From Point-of-Care Ultrasound, 1 st edition, 2014 Image Acquisition Transverse Longitudinal 21

10/9/2019 Transverse Longitudinal Complete Exam of Aorta From Point-of-Care Ultrasound, 1 st edition, 2014 22

10/9/2019 Celiac Trunk SMA From Point-of-Care Ultrasound, 1 st edition, 2014 Celiac Trunk – “Seagull Sign” Common Splenic Hepatic Artery Artery Celiac Trunk 23

10/9/2019 Celiac Trunk – “Seagull Sign” Common Splenic Hepatic Artery Artery Celiac Trunk Proximal Aorta Splenic Vein Celiac SMA Trunk Aorta From Point-of-Care Ultrasound, 1 st edition, 2014 24

10/9/2019 Proximal Aorta From Point-of-Care Ultrasound, 1 st edition, 2014 Mid-Abdominal Aorta Splenic Vein SMA Ao IVC Renal Arteries Vertebr al Body From Point-of-Care Ultrasound, 1 st edition, 2014 25

10/9/2019 Proximal Aorta Distal Aorta Right and Left Common Iliac Arteries From Point-of-Care Ultrasound, 1 st edition, 2014 26

10/9/2019 Distal Aorta From Point-of-Care Ultrasound, 1 st edition, 2014 Abdominal Aortic Aneurysm? 27

10/9/2019 Abdominal Aortic Aneurysm? Measurement of Aortic Diameter • Measure outer wall to outer wall in both transverse and longitudinal views • Normal < 3cm proximally (<2cm distally) • Diameter >4.5cm referral to vascular surgery 28

10/9/2019 AAA? From Point-of-Care Ultrasound, 1 st edition, 2014 AAA? From Point-of-Care Ultrasound, 1 st edition, 2014 29

10/9/2019 Aorta Pearls • Bowel gas limits visualization – NPO – F irm pressure or sweep transducer • Types of AAA – Fusiform – Saccular – (Pseudoaneurysm) • Measure in transverse and longitudinal planes Ultrasound for paracentesis 60 30

10/9/2019 Paracentesis: Probe + position + 61 Paracentesis: Orientation + US Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 62 31

10/9/2019 Paracentesis: Vessels 63 Safe for Para? 64 32

10/9/2019 Safe for Para? Soni N., Arntfield R., & Kory P. (2015) Point-of-Care ultrasound. Philadelphia: Elsevier 65 Goals for Scanning Stations - Can look for epigastric vessels on models - Can follow needle insertion on table trainers 66 33

10/9/2019 Ultrasound-guided Lumbar Puncture Anatomy Lumbar Spine L1 -Spinal cord ends L1 at L 1 -L 2 in adults L2 L2 - Lumbar puncture can be safely L3 L3 performed below L 2 L4 L4 L5 L5 34

10/9/2019 Lumbar Spine Longitudinal Plane Transverse Plane Spinous Process Spinous Spinous Process Process Interspino us Space Lumbar Puncture Mapping Transverse Plane 35

10/9/2019 Midline Shadow = Spinous Process L 3 – L 4 Transverse Plane Lumbar Puncture Site Mapping Longitudinal Plane 36

10/9/2019 Lumbar Puncture Mapping L5 = Deep and Small 37

10/9/2019 Lumbar Puncture Mapping  Mark 2 widest interspinous spaces  Patient must remain in position  Higher success in sitting position Lumbar Spine 38

10/9/2019 Lumbar Spine PITFALL: • Lamina / articular Erector spinae muscles processes can be mistaken for Lamina / articular processes spinous processes • No muscle should be seen superficial to spinous processes Paramedian View Lumbar Spine 39

10/9/2019 Lumbar Spine Paramedian View 40